surgical procedures for treatment of adult acquired flatfoot … · 2019. 2. 21. · treatments of...

SYSTEMATIC REVIEW Open Access

Surgical procedures for treatment of adultacquired flatfoot deformity: a networkmeta-analysisXu Tao, Wan Chen and Kanglai Tang*

Abstract

Background: Adult acquired flatfoot deformity (AAFD) represents a spectrum of deformities affecting the foot andthe ankle. The optimal management of AAFD remains controversial. We evaluated the efficacy of surgicaltreatments of AAFD using both direct and indirect evidences.

Methods: We searched PubMed, EmBase, and the Cochrane Library to identify eligible studies conducted throughNovember 2018. To compare different surgical strategies, we performed a network meta-analysis. A traditionalmeta-analysis using a random-effects model was used to evaluate the pooled outcome.

Results: A total of 21 studies including 498 patients were collected and analyzed. Network meta-analysis resultsbased on lateral angle talocalcaneal-calcaneal pitch (LAT-CP) indicated that medial displacement calcanealosteotomy (MDCO) has the highest probability to be the best course of AAFD treatment. However, analyses basedon anteroposterior talo-first metatarsal (AP-TMT1) and lateral angle talocalcaneal talo-first metatarsal (LAT-TMT1)suggested that lateral column lengthening (LCL) was the best treatment, while those based on lateral angletalocalcaneal-arch height, anteroposterior talocalcaneal (AP-TC), lateral angle talocalcaneal-talocalcaneal (LAT-TC),anteroposterior-talonavicular coverage (AP-TNC), talonavicular coverage (TNC), and the American Orthopedic Footand Ankle Society (AOFAS) indicated triple arthrodesis (TAO) as the best treatment. Moreover, double arthrodesis(DAO) provided the best treatment effect on the function score. Furthermore, according to traditional meta-analysis,the summary of standardized mean differences (SMD) indicated that the surgical interventions are associated withsignificant improvements in LAT-CP (SMD − 1.78), LAT-arch height (SMD − 4.95), AOFAS (SMD − 5.24), AP-TMT1(SMD 2.45), LAT-TMT1 (SMD 1.97), AP-TC (SMD 3.05), LAT-TC (SMD 2.20), AP-TNC (SMD 2.07), TNC (SMD 1.70), andfunction score (SMD 0.95).

Conclusions: Our findings indicated that MDCO, LCL, TAO, or DAO might be the best surgical approaches forAAFD treatment. Furthermore, patients who received surgical interventions had significant improvements insymptoms and function.

Keywords: Adult acquired flatfoot deformity, Surgical treatment, Meta-analysis

* Correspondence: [email protected] of Orthopedic Surgery, Southwest Hospital, Army MedicalUniversity, Chongqing 400038, China

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Tao et al. Journal of Orthopaedic Surgery and Research (2019) 14:62 https://doi.org/10.1186/s13018-019-1094-0

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BackgroundAdult acquired flatfoot deformity (AAFD) is a degenera-tive disease characterized by pathological changes in thetibialis posterior tendon, spring ligament complex, deltoidligament, and other ligaments of the hindfoot [1]. This isdivided into four stages. Stage I is characterized by painand swelling in the tibialis posterior tendon but have nor-mal alignment. Stage II is characterized by flexible de-formities in the foot and can also include the hindfootvalgus, varying arch height, and degrees of abduction andsupination of the forefoot. Stage III is similar to stage II,but the deformities are more severe and are rigid ratherthan flexible. Lastly, stage IV is characterized by fixed de-formities and valgus tilting of the talus [2–4]. The patho-genesis of AAFD still remains unclear. The possiblepathogenic factors include varying stresses on surroundingjoints and weakening of the dynamic and static ligament-ous restraints of the hindfoot and midfoot [1].The treatment of AAFD involves slowing down the

progression of the disease. Surgical techniques, such assoft tissue with medial or lateral column procedures, arewidely used to avoid the progression of these fixed de-formities [1]. According to a previous study, the medialsurgical approach permitted fusion without the develop-ment of non-union and provided a significant correctionof the fixed deformities. However, there are limited stud-ies that compared the efficacy among these surgicaltechniques, and the best approach for treating AAFDstill remains controversial.Currently, the common surgical procedures included

medial displacement calcaneal osteotomy (MDCO), lat-eral column lengthening (LCL), modified triple arthrod-esis (MTA), and flexor digitorum longus (FDL) transfer.These strategies are widely used for mild deformitieswith flexibility, whereas no quantitative indexes are con-structed for operative indication. Previous studies haveshowed that these interventions can slow down the pro-gression and relieve the clinical symptoms of AAFD, buta clear comparison of the efficacy among these surgicalprocedures is still needed [5, 6]. Hence, this networkmeta-analysis aimed to use both direct and indirect evi-dences to evaluate the comparative efficacy of surgicalprocedures in AAFD patients.

MethodsData sources, search strategy, and selection criteriaThis review was conducted and reported according tothe Preferred Reporting Items for Systematic Reviewsand Meta-Analysis Statement, 2009 (Additional file 1:PRISMA Checklist) [7].We performed systematic searches in PubMed, EmBase,

and the Cochrane Library for relevant literature that ispublished on or before November 2018. The followingterms were used separately in the search: “posterior tibial

tendon dysfunction,” “pes planus,” “adult acquired flatfootdeformity,” “midfoot abduction,” “posterior tibial tendon,”“pes planovalgus,” “posterior tibial tendon insufficiency,”“flatfoot staging,” “flatfoot treatment,” “foot orthoses,” and“surgical”. The resulting titles and abstracts of the primarycollections were browsed. To identify additional candidatestudies, the reference lists of the included studies and re-views were also evaluated.The literature search was performed by two independ-

ent authors, and any inconsistencies between them weresettled by group discussion until a consensus wasreached. A study was considered eligible for inclusion ifthe following criteria were met: (1) the trials that investi-gated surgical procedures for the treatment of AAFD pa-tients and (2) the authors’ outcome reports includedlateral angle talocalcaneal-calcaneal pitch (LAT-CP), an-teroposterior talo-first metatarsal (AP-TMT1), lateralangle talocalcaneal talo-first metatarsal (LAT-TMT1),LAT-arch height, anteroposterior talocalcaneal (AP-TC),lateral angle talocalcaneal-talocalcaneal (LAT-TC),anteroposterior-talonavicular coverage (AP-TNC), TNC,the American Orthopedic Foot and Ankle Society(AOFAS), and function score. Cohorts, case controls,case series, reviews, and editorials were excluded due touncontrolled confounders.

Data collection and quality assessmentTwo reviewers independently extracted all the data, anddisagreements were resolved in consultation withthird-party investigators. The following information wasextracted from the included articles: first author, publi-cation year, country, prospective or retrospective design,age, follow-up duration, disease type, surgery type, re-ported outcomes, and number of patients. The investi-gated outcomes from radiography examination includedLAT-CP, AP-TMT1, LAT-TMT1, LAT-arch height,AP-TC, LAT-TC, AP-TNC, TNC, AOFAS, and functionscore. Two reviewers independently assessed the qualityof the included studies according to the Jadad scale inthe following five domains: randomization (1 or 0), con-cealment of the treatment allocation (1 or 0), blinding (1or 0), completeness of follow-up (1 or 0), and the use ofintention-to-treat analysis (1 or 0). Based on these re-sults, the studies were given scores with a previously de-veloped scoring system for quality assessment thatranged from 1 to 5 [8].

Statistical analysisFor traditional meta-analyses, we used the inverse variancemethod to pool the continuous data. The results are pre-sented as standardized mean difference (SMD) with 95%confidence intervals (95%CIs). In our networkmeta-analysis, we used a random-effect networkmeta-analysis for mixed multiple treatment comparisons,

Tao et al. Journal of Orthopaedic Surgery and Research (2019) 14:62 of 12

which fully preserves the within-trial randomized treatmentcomparisons of each trial [9].The I2 statistic was calculated to evaluate the extent of

variability that was attributable to statistical heterogeneitybetween the trials. In the absence of statistical heterogeneity(I2 < 50%), we used a fixed-effects model; otherwise, weused a random-effects model in a traditional meta-analysis[10, 11]. Consistency within every closed triangle or quad-ratic loop was investigated using a loop-specific approachin our network meta-analysis. During analysis, inconsist-ency factors and their 95%CIs were used to determine theircompatibility with zero [12]. To rank the treatments for anoutcome, we used surface under the cumulative ranking(SUCRA) probabilities [13]. A “comparison-adjusted” fun-nel plot was used to assess the presence of small-study ef-fects in our network meta-analysis [14]. All tests weretwo-tailed, and p value of less than 0.05 was deemed to bestatistically significant. We analyzed the data using STATAsoftware (version 10.0).

ResultsOur initial search produced 1798 unique results. Of these,we collected 21 trials that met our study criteria, which in-cluded 498 patients [15–35] (Fig. 1). After reviewing the fulltexts, the reasons for the exclusion of literature includedother intervention interferences, other similar diseases, andlack of desired outcome assessment. The general character-istics of the included studies are presented in Table 1. Ofthe included studies, 10 were conducted in the US, 5 inEurope, 4 in China, 1 in Japan, and 1 in Egypt. Study qualitywas evaluated using the Jadad scale (Table 1). Overall, 8studies had a score of 2, 10 studies had a score of 1, andthe remaining 3 studies had a score of 0.Traditional meta-analysis was used to evaluate the ef-

fect of surgical intervention for AAFD, and a summaryof the outcomes is listed in Table 2. Overall, we notedthat surgical intervention was associated with lowerlevels of LAT-CP (SMD − 1.78; 95%CI − 2.57 to − 0.99;p < 0.001; I2 92.4%), LAT-arch height (SMD − 4.95;95%CI − 5.69 to − 4.20; p < 0.001; I2 0.0%), and AOFAS(SMD − 5.24; 95%CI − 6.98 to − 3.49; p < 0.001; I2

90.7%). Furthermore, surgical treatments were associatedwith AAFD patients with higher levels of AP-TMT1(SMD 2.45; 95%CI 1.74 to 3.17; p < 0.001; I2 91.5%),LAT-TMT1 (SMD 1.97; 95%CI 1.18 to 2.77; p < 0.001; I2

95.4%), AP-TC (SMD 3.05; 95%CI 1.37 to 4.73; p <0.001; I2 96.2%), LAT-TC (SMD 2.20; 95%CI 0.98 to3.42; p < 0.001; I2 94.8%), AP-TNC (SMD 2.07; 95%CI1.04 to 3.09; p < 0.001; I2 92.1%), TNC (SMD 1.70;95%CI 1.00 to 2.40; p < 0.001; I2 83.1%), and functionscore (SMD 0.95; 95%CI 0.24 to 1.67; p = 0.009; I2

90.7%). Although substantial heterogeneity was detectedfor most of the outcomes, the conclusions were not af-fected by the sequential exclusion of any single study.

The eligible LAT-CP comparisons in our networkmeta-analysis are predominantly pairwise comparisonsof different surgical interventions for AAFD patients(Fig. 2). The modes in Fig. 2 are weighted according tothe number of patients that received each surgical mode,and the edges are weighted according to the mean con-trol group for all comparisons versus the correspondingpreoperative values. The MDCO versus preoperativetreatment demonstrated the highest contribution for theentire network meta-analysis. The LAT-CP resultsshowed that the LAT-CP values following TAO (SMD −6.24; 95%CI − 11.59 to − 0.89) or MDCO (SMD − 9.31;95%CI − 18.59 to − 0.12) are significantly lower than thecorresponding preoperative values, but none of the othercomparisons revealed significant differences.A similar analysis suggested that LCL is the best treat-

ment strategy based on the changes in AP-TMT1 (Fig. 3)and LAT-TMT1 values (Fig. 4). All types of surgical strat-egies for treating AAFD except for medial translationalosteotomy (MTO) are associated with lower AP-TMT1values (SMD − 2.60; 95%CI − 9.01 to 3.80; Fig. 3). Add-itionally, the double arthrodesis (DAO), TAO, and LCLshowed significant reduction in the levels of LAT-TMT1as compared with corresponding preoperative values(Fig. 4). Finally, TAO showed the highest probability asthe best treatment strategy based on changes in theLAT-arch height (Fig. 5), AP-TC (Fig. 6), ALT-TC (Fig. 7),AP-TNC (Fig. 8), TNC (Fig. 9), AOFAS (Fig. 10), andfunction scores (Fig. 11).Both DAO and TAO were associated with higher

LAT-arch height values (Fig. 5), increased AOFAS levels(SMD 33.48 and 95%CI 28.14 to 38.82 for DAO; SMD44.30 and 95%CI 32.58 to 56.02 for TAO; Fig. 10), and

With other treatment (n=5)

Abstracts and title excluded during first screening (n=1699)

Articles reviewed in details (n=43)

Articles excluded (n=22)

21 studies included in meta-analysis

Potential articles from PubMed,

Embase and Cochrane (n=1742)

No desirable outcomes (n=17)

Fig. 1 Flow diagram showing the study selection process


Table

1Baselinecharacteristic

ofstud

iesinclud

edin

thesystem

aticreview

andmeta-analysis

Stud

yPu

blication

year

Cou

ntry

Sample

size

Mean

age

Follow-up

Disease

status

Surgerytype

Jadad

score

MarkS

1995

America

1854.0

(12–16)mon

ths

AAFD

second

aryto

PTTI

MDCO,FDL,MTC

P1

Beat

Hinterm

ann

1999

Switzerland

1952.9

35.8(12–37)

mon

ths

PTTI

LCL,med

ialsofttissuereconstructio

n2

CharlesM

1999

America

1048.7

35(8–60)

mon

ths

StageII/IIIPTTD

EvansLC

L,TN

fusion

1

AlanR

2000

America

2453.7

27(13–51)

mon

ths

PTTD

andAAFD

PCDO,FDL,ATL

1

G.Jam

esSammarco

2001

America

1760.0

17(11–24)

mon

ths

StageIIPTTD

MDCO,FHL

2

Grego

ryP

2001

America

2654.0

31.8(12–70)

mon

ths

StageIIPTTD

FDL,MDCO

1

AmirH.

2002

America

2356.0

35(24–51)

mon

ths

StageIIPTTD

FDL,calcanealo

steo

tomy

2

G.A.

2003

Nethe

rland

s14

62.0

42(6–78)

mon

ths

StageIIPTTD

CCbo

ne-block

arthrode

sis,med

ialsofttissuereconstructio

n2

Arie

vande

rKrans

2006

Nethe

rland

s20

55.0

25.3(13–39)

mon

ths

Acquiredflatfoo

tandPTDLS

LCL,ATL,FDL

2

PatrickM.

2007

America

4046.5

30.5(12–96)

mon

ths

AAFD

LCL,MTO

,FDL,GR,TM

T2

Kang

-laiTang

2010

China

1041.8

13.2(6–21)

mon

ths

StageIIandIIB

AAFD

Osteo

tomyof

subtalar

joint,talonavicularjoint,andcalcaneo

cubo

idjoint

1

RémiP

hilippo

t2010

France

1459.4

20.6(12–54)

mon

ths

Pesplanovalgu

sSubtalar

andtalonavicularjointarthrode

ses

0

Guu

sA.

2010

Nethe

rland

s33

57.8

29.2(6–78)

mon

ths

Flexibleacqu

iredflatfoo

tLeng

then

ingcalcaneusosteotom

y,CCJdistractionarthrode

sis

1

YehiaBasion

i2011

Egypt

1423.0

22(13–34)

mon

ths

Flexibleadultacqu

iredflatfoo

tEvansosteotom

yandpo

steriorcalcaneald

isplacem

entosteotom

y1

Thom

asH.

2011

America

4152.0

9.6(3–43)

mon

ths

AAFD

Med

ialcolum

narthrode

sis,MDCO

2

Hon

g-hu

iCao

2012

China

3330.1

23.0(6–54)

mon

ths

Flatfoot

relatedwith

accessory

navicular

Reconstructio

nof

posteriortib

ialten

don

1

HisateruNiki

2012

Japan

2555.2

5.6(2.6–10.2)

years

StageIIPTTD

MDCO,FDL

0

Michael

Iossi

2013

America

6855.0

9(2–30)

mon

ths

AAFD

FDL,MDCO,LCL

2

Sidd

hant

K.2013

America

2168.0

13(6–44)

mon

ths

StageIIPTTD

Fusion

sof

thesubtalar,talon

avicular,and

firsttarsom

etatarsaljoints

1

Hon

g-hu

iCao

2014

China

1641.5

12mon

ths

Flexibleflatfoo

tMDCO,recon

structionof

thePTT

1

Guang

rong

Yu2014

China

1253.3

19.4(13–30)

mon

ths

Flatfoot

deform

itywith

pesvalgus

Subtalar

andtalonavicularjointsarthrode

sisthroug

hasing

lemed

ialincisionapproach

0


lower ALT-TC levels (SMD − 6.71 and 95%CI − 12.54 to− 0.89 for DAO; SMD − 11.91 and 95%CI − 17.96 to −5.87 for TAO; Fig. 7). Patients who received DAO hadsignificantly lower AP-TC values (SMD − 9.09; 95%CI −17.00 to − 1.18; Fig. 6), and those who received TAOhad significantly reduced levels of AP-TNC (SMD −25.17; 95%CI − 38.63 to − 11.71; Fig. 8). DAO and CJDAwere associated with significantly lower levels of TNC(SMD − 13.26 and 95%CI − 23.59 to − 2.93 for DAO;SMD − 20.60 and 95%CI − 41.14 to − 0.06 for CJDA;Fig. 9). Furthermore, TAO was associated with lowerfunction scores, whereas DAO significantly increasedthe function scores.

DiscussionThis meta-analysis included 21 studies that evaluatedsurgical interventions in adult patients with AAFD. Ourfindings suggested that surgical interventions showed a

significant impact on LAT-CP, AP-TMT1, LAT-TMT1,LAT-arch height, AP-TC, LAT-TC, AP-TNC, TNC,AOFAS, and function score. Additionally, we conductedthe first network meta-analysis to analyze the effects ofdifferent types of surgery for the treatment of AAFD.The results of these analyses indicated that MDCO,LCL, TAO, and DAO might be superior to other surgicalapproaches for treating AAFD.The methodological evaluation of each included study

was limited by randomization, blinding, allocation con-cealment, withdrawals and dropouts, and the use ofintention-to-treat analysis. In this study, all the includedstudies were self-contrast trials, and no trial requiredrandomization, blinding, or allocation concealment. Al-though most of the trials reported withdrawals, drop-outs, and the use of intention-to-treat analysis, otherbiases also contributed to heterogeneity in each study.Ultimately, taking into consideration the unsatisfactory

Fig. 2 Comparisons of different surgical interventions for AAFD

Table 2 Summary of the standard mean difference of all outcomes assessed by using traditional meta-analysisOutcomes SMD 95% CI p value Heterogeneity (%) p value for heterogeneity

LAT-CP − 1.78 − 2.57 to − 0.99 < 0.001 92.4 < 0.001

AP-TMT1 2.45 1.74 to 3.17 < 0.001 91.5 < 0.001

LAT-TMT1 1.97 1.18 to 2.77 < 0.001 95.4 < 0.001

LAT-arch height − 4.95 − 5.69 to − 4.20 < 0.001 0.0 0.398

AP-TC 3.05 1.37 to 4.73 < 0.001 96.2 < 0.001

LAT-TC 2.20 0.98 to 3.42 < 0.001 94.8 < 0.001

AP-TNC 2.07 1.04 to 3.09 < 0.001 92.1 < 0.001

TNC 1.70 1.00 to 2.40 < 0.001 83.1 < 0.001

AOFAS − 5.24 − 6.98 to − 3.49 < 0.001 90.7 < 0.001

Function score 0.95 0.24 to 1.67 0.009 90.7 < 0.001


quality of the included studies, we critically provided ourrecommendations for the treatment of patients withAAFD.Cao et al. reported that MDCO with reconstruction of

the posterior tibial tendon insertion on the navicularbone is considered as an effective treatment for flexibleflatfoot with symptomatic accessory navicular and thatthis method is associated with excellent clinical

outcomes and correction of the deformity [30]. Mehta etal. found that MTA showed a reliable and reproduciblecorrection of the deformity seen in rigid stage III poster-ior tibial tendon dysfunction [33]. Iossi et al. suggestedthat clinical and radiographic parameters are also im-portant to consider when choosing bony realignmentprocedures to reconstruct a flexible flatfoot deformity[32]. For the treatment of more severe deformities, LCL

Fig. 4 The effect of different treatment strategies based on changes in LAT-TMT1 values

Fig. 3 The effect of different treatment strategies based on changes in AP-TMT1 values


resulted in a greater radiographic improvement in align-ment. A MDCO alone is also a valuable tool to correctthese deformities, although it provides a different levelof correction when compared with LCL. Overall, the di-verse outcome assessments used in various interventionsremains to be the greatest obstacle for the improvementof treatments for AADF, because it is difficult to

compare these non-uniform results. Therefore, a system-atic review was needed to define the comparison amongthe surgical approach treatments.The intervention methods tested in our included

studies were restricted to surgical treatments becausethey are widely used as the first-line treatments inAAFD patients. To increase the reliability of our

Fig. 6 The effect of different treatment strategies based on changes in AP-TC

Fig. 5 The effect of different treatment strategies based on changes in the LAT-Arch height


Fig. 8 The effect of different treatment strategies based on changes in AP-TNC

Fig. 7 The effect of different treatment strategies based on changes in ALT-TC


study, we excluded the studies with high design biasbecause the treatment and outcome records of AADF,especially the pain and urgency records, are subjectedto high subjectivity. We also comparatively analyzedthe various surgical treatment approaches by networkmeta-analysis.

Various surgical types are currently used for AAFD treat-ment, but there is no widely accepted effective treatment todate. These surgical types include LCL, MTO, TAO, DAO,MCA, MCA, MDCO, excision of accessory navicular withreconstruction of posterior tibial tendon insertion on na-vicular, FDL, MTA, and reconstruction of the PTT. Our

Fig. 10 The effect of different treatment strategies based on changes in AOFAS

Fig. 9 The effect of different treatment strategies based on changes in TNC


network meta-analysis suggested that among thesemethods, MDCO, LCL, and TAO might be considered asrelatively better surgical strategies for the treatment of pa-tients with AAFD.The results of our traditional meta-analysis re-

vealed that AAFD patients who received a surgicalintervention showed significant improvement withLAT-CP, AP-TMT1, LAT-TMT1, LAT-arch height,AP-TC, LAT-TC, AP-TNC, TNC, AOFAS, and func-tion score values when compared with their pre-operative levels. However, several studies reportedinconsistent results. Firstly, Iossi et al. showed that aFDL transfer to the navicular and bony realignmentshowed no significant impact on the function score,whereas the LCL results showed a greater radio-graphic improvement in alignment [32]. Further-more, Haeseker et al. suggested that LCL by meansof calcaneus osteotomy rather than distraction arth-rodesis of the calcaneocuboid joint assists in the cor-rection of stage II posterior tibial tendondysfunction, but showed no effect on the functionscore [27]. As there were only few trials reported foreach specific surgical strategy, and so we could notconduct a stratified analysis based on the types ofsurgical intervention. However, we were able to com-prehensively compare these methods by performing anetwork meta-analysis.Our study has few limitations. Firstly, we did not

have access to specific data of individuals for all thetrials, and so our statistical analysis could only be

performed at a study level. Secondly, there are limitedstudies using single treatment, which in turn couldreduce the reliability of our meta-analysis. Thirdly,there was heterogeneity in most of the outcomesamong the included studies, attributing to the non-stan-dardization of outcome assessment. Fourthly, thepre-operative stages of patients might affect the treat-ment effects of surgical strategies, whereas most ofthe included studies did not provide these informa-tion in detail. Finally, we were not able to use a sub-group analysis and meta-regression to reduce theheterogeneity because there were too few studiesusing a single surgical intervention for the treatmentof AADF. Therefore, unifying the outcome standard isvery important for further research to improvise thetreatments for AADF.

ConclusionThe findings of this study suggested that surgicalintervention in AADF patients is associated withbeneficial prognosis. Furthermore, MDCO, LCL, andTAO are the three surgical strategies that showed themost effective treatments in patients with AAFD. Fur-ther research would not only benefit from theaddition of well-designed studies, but also from thepublication of studies that focused on the pathogen-esis and therapeutic mechanisms of AADF, which fur-ther improves the understanding of the disease andits treatments.

Fig. 11 The effect of different treatment strategies based on changes in the function scores


Additional file

Additional file 1: PRISMA Checklist. (DOC 72 kb)

AbbreviationsAAFD: Adult acquired flatfoot deformity; AOFAS: American Orthopedic Footand Ankle Society; AP-TC: Anteroposterior talocalcaneal; AP-TMT1: Anteroposterior talo-first metatarsal; AP-TNC: Anteroposterior-talonavicular coverage; DAO: Double arthrodesis; FDL: Flexor digitorumlongus; LAT-CP: Lateral angle talocalcaneal-calcaneal pitch; LAT-TC: Lateralangle talocalcaneal-talocalcaneal; LCL: Lateral column lengthening;MDCO: Medial displacement calcaneal osteotomy; MTA: Modified triplearthrodesis; SMD: Standardized mean differences; SUCRA: Surface under thecumulative ranking; TAO: Triple arthrodesis

AcknowledgementsNot applicable.

FundingNot applicable.

Availability of data and materialsThe data set supporting the results of this article are included within thearticle.

Authors’ contributionsXT conceived and coordinated the study, designed, performed, and analyzedthe experiments, and wrote the paper. WC carried out the data collection,data analysis, and revised the paper. KT designed the study, carried out thedata analysis, and revised the paper. All authors reviewed the results andapproved the final version of the manuscript.

Ethics approval and consent to participateNot applicable.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Received: 29 September 2018 Accepted: 5 February 2019

References1. Kelly IP, Easley ME. Treatment of stage 3 adult acquired flatfoot. Foot Ankle

Clin. 2001;6:153–66.2. Haddad SL, Myerson MS, Younger A, Anderson RB, Davis WH, Manoli A 2nd.

Symposium: adult acquired flatfoot deformity. Foot Ankle Int. 2011;32:95–111.3. Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clin Orthop

Relat Res. 1989;239:196–206.4. Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of

the posterior tibial tendon. Instr Course Lect. 1997;46:393–405.5. Hiller L, Pinney SJ. Surgical treatment of acquired flatfoot deformity: what is

the state of practice among academic foot and ankle surgeons in 2002?Foot Ankle Int. 2003;24:701–5.

6. Zaw H, Calder JD. Operative management options for symptomatic flexibleadult acquired flatfoot deformity: a review. Knee Surg Sports TraumatolArthrosc. 2010;18:135–42.

7. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reportingitems for systematic reviews and meta-analyses: the PRISMA statement.PLoS Med. 2009;6:e1000097.

8. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, etal. Assessing the quality of reports of randomized clinical trials: is blindingnecessary? Control Clin Trials. 1996;17:1–12.

9. Bucher HC, Guyatt GH, Griffith LE, Walter SD. The results of direct andindirect treatment comparisons in meta-analysis of randomized controlledtrials. J Clin Epidemiol. 1997;50:683–91.

10. White IR, Barrett JK, Jackson D, Higgins JP. Consistency and inconsistency innetwork meta-analysis: model estimation using multivariate meta-regression. Res Synth Methods. 2012;3:111–25.

11. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency inmeta-analyses. BMJ. 2003;327:557–60.

12. Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ. 2011;342:d549.

13. Chaimani A, Higgins JP, Mavridis D, Spyridonos P, Salanti G. Graphical toolsfor network meta-analysis in STATA. PLoS One. 2013;8:e76654.

14. Trinquart L, Chatellier G, Ravaud P. Adjustment for reporting bias in networkmeta-analysis of antidepressant trials. BMC Med Res Methodol. 2012;12:150.

15. Myerson MS, Corrigan J, Thompson F, Schon LC. Tendon transfer combinedwith calcaneal osteotomy for treatment of posterior tibial tendoninsufficiency: a radiological investigation. Foot Ankle Int. 1995;16:712–8.

16. Hintermann B, Valderrabano V, Kundert HP. Lengthening of the lateralcolumn and reconstruction of the medial soft tissue for treatment ofacquired flatfoot deformity associated with insufficiency of the posteriortibial tendon. Foot Ankle Int. 1999;20:622–9.

17. Lombardi CM, Dennis LN, Connolly FG, Silhanek AD. Talonavicular jointarthrodesis and Evans calcaneal osteotomy for treatment of posterior tibialtendon dysfunction. J Foot Ankle Surg. 1999;38:116–22.

18. Catanzariti AR, Lee MS, Mendicino RW. Posterior calcaneal displacementosteotomy for adult acquired flatfoot. J Foot Ankle Surg. 2000;39:2–14.

19. Sammarco GJ, Hockenbury RT. Treatment of stage II posterior tibial tendondysfunction with flexor hallucis longus transfer and medial displacementcalcaneal osteotomy. Foot Ankle Int. 2001;22:305–12.

20. Guyton GP, Jeng C, Krieger LE, Mann RA. Flexor digitorum longus transfer andmedial displacement calcaneal osteotomy for posterior tibial tendondysfunction: a middle-term clinical follow-up. Foot Ankle Int. 2001;22:627–32.

21. Fayazi AH, Nguyen HV, Juliano PJ. Intermediate term follow-up of calcanealosteotomy and flexor digitorum longus transfer for treatment of posteriortibial tendon dysfunction. Foot Ankle Int. 2002;23:1107–11.

22. Haeseker GA, Faber FWM. Calcaneo-cuboid distraction arthrodesiscombined with medial soft tissue reconstruction for posterior tibial tendondysfunction stage II. Foot Ankle Surg. 2003;9:157–60.

23. van der Krans A, Louwerens JW, Anderson P. Adult acquired flexible flatfoot,treated by calcaneocuboid distraction arthrodesis, posterior tibial tendonaugmentation, and percutaneous Achilles tendon lengthening: aprospective outcome study of 20 patients. Acta Orthop. 2006;77:156–63.

24. Bolt PM, Coy S, Toolan BC. A comparison of lateral column lengthening andmedial translational osteotomy of the calcaneus for the reconstruction ofadult acquired flatfoot. Foot Ankle Int. 2007;28:1115–23.

25. Tang KL, Zhou JB, Yang HF, Tan XK, Xie MM, Tao X, et al. Triple arthrodesiswith osteotomy for the treatment of stage IIB and stage III adult-acquiredflatfoot deformity. Zhonghua Yi Xue Za Zhi. 2010;90:2313–6.

26. Philippot R, Wegrzyn J, Besse JL. Arthrodesis of the subtalar andtalonavicular joints through a medial surgical approach: a series of 15 cases.Arch Orthop Trauma Surg. 2010;130:599–603.

27. Haeseker GA, Mureau MA, Faber FW. Lateral column lengthening for acquiredadult flatfoot deformity caused by posterior tibial tendon dysfunction stage II:a retrospective comparison of calcaneus osteotomy with calcaneocuboiddistraction arthrodesis. J Foot Ankle Surg. 2010;49:380–4.

28. Basioni Y, El-Ganainy AR, El-Hawary A. Double calcaneal osteotomy andpercutaneous tenoplasty for adequate arch restoration in adult flexible flatfoot. Int Orthop. 2011;35:47–51.

29. Jordan TH, Rush SM, Hamilton GA, Ford LA. Radiographic outcomes of adultacquired flatfoot corrected by medial column arthrodesis with or without amedializing calcaneal osteotomy. J Foot Ankle Surg. 2011;50:176–81.

30. Cao H, Tang K, Deng Y, Tan X, Zhou B, Tao X, et al. Excision ofaccessory navicular with reconstruction of posterior tibial tendoninsertion on navicular for treatment of flatfoot related withaccessory navicular. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi.2012;26:686–90.

31. Niki H, Hirano T, Okada H, Beppu M. Outcome of medial displacement calcanealosteotomy for correction of adult-acquired flatfoot. Foot Ankle Int. 2012;33:940–6.

32. Iossi M, Johnson JE, McCormick JJ, Klein SE. Short-term radiographicanalysis of operative correction of adult acquired flatfoot deformity.Foot Ankle Int. 2013;34:781–91.


https://doi.org/10.1186/s13018-019-1094-0

33. Mehta SK, Kellum RB, Robertson GH, Moore AR, Wingerter SA, Tarquinio TA.Radiographic correction of stage III posterior tibial tendon dysfunction witha modified triple arthrodesis. Foot Ankle Int. 2013;34:1355–63.

34. Cao HH, Tang KL, Lu WZ, Xu JZ. Medial displacement calcaneal osteotomywith posterior tibial tendon reconstruction for the flexible flatfoot withsymptomatic accessory navicular. J Foot Ankle Surg. 2014;53:539–43.

35. Yu G, Yu T, Yang Y, Li B, Zhu H, Chen K, et al. Double arthrodesis through asingle medial incision approach for flatfoot. Zhongguo Xiu Fu Chong JianWai Ke Za Zhi. 2014;28:1321–4.


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